Methods and compositions for the treatment of asthma and related disorders

ABSTRACT

The present invention provides methods for the treatment of respiratory tract mucositis in individuals in need of such treatment, the method comprising the systemic administration to the individual of therapeutically effective amounts of at least one anti-fungal agent and at least one anti-bacterial agent, wherein the treatment does not involve the cessation of use of emollients by the individual. The present invention also provides compositions suitable for use in the treatment of respiratory tract mucositis.

CROSS-REFERENCE RELATED APPLICATIONS

This application is a continuation application Ser. No. 10/897,714 filedJul. 23, 2004, which was a continuation application of PCT/AU03/00074filed on Jan. 24, 2003, which claims priority to Australian ApplicationNo. PS0177, filed on Jan. 25, 2002, all of which are incorporated hereinby reference in their entirety.

FIELD OF THE INVENTION

This invention relates to methods for the treatment of mucositisincluding asthma and related disorders such as chronic bronchitis andsinusitis, and to pharmaceutical compositions for use in such treatment.

BACKGROUND OF THE INVENTION

Mucositis refers to inflammation of the mucous membranes caused by aninfection. In the respiratory tract, mucositis affects not only thenose, sinuses and the large airways but also the small airways of thelungs. Mucositis of the nose and sinuses is called chronicrhinosinusitis. In the smaller airways it is termed asthma.

Asthma is a common disorder causing marked morbidity and significantmortality. The incidence of asthma in the United States and otherWestern countries is over 5% and growing. In the US alone asthma affectsapproximately 17 million people and accounts for nearly half a millionhospital admissions each year.

In general the cause of chronic mucositis in the respiratory tract isnot known. However, in a percentage of patients, superficial ornon-invasive fungal organisms appear to be present within the mucus. Itappears that respiratory tract mucositis is caused, at least in part, bya chronic fungal infection.

Typically, mucositis may be treated with surgery, steroid therapy oranti-inflammatory agents. However such therapies fail to address theinfection components of the mucositis.

Alternatively treatment may include mucosal administration of ananti-fungal agent. U.S. Pat. No. 6,291,500 (Ponikau) describes thetreatment of non-invasive fungus-induced mucositis by mucosaladministration of a formulation including an anti-fungal agent.According to Ponikau, the formulation may also include an antibiotic.

The Applicant has noted that although such mucosal administration canreduce symptoms of mucositis, suppress severity or reduce relapses ofthe condition if administered for a long period of time, this type oftherapy of an anti-fungal agent administered superficially to the mucosasuffers from the disadvantage that it does not address the invasivecomponent of the fungal infection. Indeed mucosal administration has thepotential to lead to the development of resistant fungi where only asmall amount of the anti-fungal agent reaches the fungi inhabiting thedeeper layers of mucosal membranes allowing them to multiply at lowlevels of anti-fungal exposure, thereby exacerbating the underlyingproblem.

WO 02/07682 (Vyden) describes the treatment of atopic disorders,including asthma, using an anti-fungal agent and an antibiotic, whereinthe treatment also requires the reduction or cessation of use ofemollients by the patient.

The Applicant has surprisingly found, however, that such reduction orcessation of emollient use is in fact often unnecessary, and effectivetreatment of asthma and other respiratory tract mucositis can beachieved using at least one anti-fungal agent and at least oneanti-bacterial agent without need for a reduction or cessation of use ofemollients.

It is an object of the present invention to provide an effectivetreatment for respiratory tract mucositis which overcomes or at leastsubstantially ameliorates the shortcomings of the prior art.

SUMMARY OF THE INVENTION

According to a first aspect of the present invention there is provided amethod for the treatment of respiratory tract mucositis in an individualin need of such treatment, the method comprising the systemicadministration to the individual of therapeutically effective amounts ofat least one anti-fungal agent and at least one anti-bacterial agent,wherein the treatment does not involve the cessation of use ofemollients by the individual.

According to a second aspect of the present invention there is provideda method for the treatment of respiratory tract mucositis in anindividual in need of such treatment, the method comprising the systemicadministration to the individual of therapeutically effective amounts ofat least one anti-fungal agent and two or more anti-bacterial agents.Typically, there are administered one anti-fungal agent and twoanti-bacterial agents. Optionally, the treatment may further include thereduction or cessation of the use of emollients by the individual.

Typically the at least one anti-fungal agent is selected from the groupconsisting of: amphotericin B, flucytosine, ketoconazole, miconazole,itraconazole, fluconazole, griseofulvin, clotrimazole, econazole,terconazole, butoconazole, oxiconazole, sulconazole, supraconazole,voriconazole, ciclopirox olamine, haloprogin, tolnaftate, naftifine,terbinafine hydrochloride, morpholines, nystatin, natamycin, butenafine,undecylenic acid, proprionic acid and caprylic acid.

More typically the at least one anti-fungal agent is selected from thesub-group consisting of: amphotericin B; ketoconazole; fluconazole; andterbinafine hydrochloride.

Typically the at least one anti-bacterial agent belongs to one or moreof the following classes: tetracyclines, penicillins, macrolides,quinolones, chloramphenicol, rifamycins, sulphonamides, co-trimoxazole,and oxazolidinones.

More typically the at least one anti-bacterial agent is a tetracycline,a macrolide or a rifamycin.

Most typically the at least one anti-bacterial agent is selected fromthe group consisting of: doxycycline, chlortetracycline, tetracyclinehydrochloride, oxytetracycline, demeclocycline, methacycline,minocycline, penicillin, amoxycillin, erythromycin, clarithromycin,roxithromycin, azithromycin, spiramycin, oleandomycin, josamycin,kitsamysin, flurithromycin, nalidixic acid, oxolinic acid, norfloxacin,perfloxacin, amifloxacin, ofloxacin, ciprofloxacin, sparfloxacin,levofloxacin, rifabutin, rifampicin, rifapentin, sulfisoxazole,sulfamethoxazole, sulfadiazine, sulfadoxine, sulfasalazine,sulfaphenazole, dapsone, sulfacytidine, and linezolid.

The at least one anti-fungal agent and at least one anti-bacterial agentmay be administered sequentially, or simultaneously.

In a preferred embodiment of the method of the invention there isadministered to an individual a pharmaceutical composition comprisingone anti-fungal agent selected from the above-mentioned group combinedwith two or more anti-bacterial agents selected from the groupconsisting of: doxycycline, chlortetracycline, tetracyclinehydrochloride, oxytetracycline, demeclocycline, methacycline,minocycline, penicillin, amoxycillin, erythromycin, clarithromycin,roxithromycin, azithromycin, spiramycin, oleandomycin, josamycin,kitsamysin, flurithromycin, nalidixic acid, oxolinic acid, norfloxacin,perfloxacin, amifloxacin, ofloxacin, ciprofloxacin, sparfloxacin,levofloxacin, rifabutin, rifampicin, rifapentin, sulfisoxazole,sulfamethoxazole, sulfadiazine, sulfadoxine, sulfasalazine,sulfaphenazole, dapsone, sulfacytidine, and linezolid.

In a particularly preferred embodiment there is administered to anindividual a pharmaceutical composition comprising the anti-fungal agentterbinafine hydrochloride and the anti-bacterial agents doxycycline andrifabutin.

In a particularly preferred embodiment there is administered to anindividual a pharmaceutical composition comprising the anti-fungal agentterbinafine hydrochloride and the anti-bacterial agents clarithromycinand rifampicin.

In a particularly preferred embodiment there is administered to anindividual a pharmaceutical composition comprising the anti-fungal agentterbinafine hydrochloride and the anti-bacterial agents doxycycline andrifampicin.

In a particularly preferred embodiment there is administered to anindividual a pharmaceutical composition comprising the anti-fungal agentterbinafine hydrochloride and the anti-bacterial agents clarithromycinand rifabutin.

In a particularly preferred embodiment there is administered to anindividual a pharmaceutical composition comprising the anti-fungal agentterbinafine hydrochloride and the anti-bacterial agents tetracyclinehydrochloride and rifampicin.

In a particularly preferred embodiment there is administered to anindividual a pharmaceutical composition comprising the anti-fungal agentfluconazole and the anti-bacterial agents clarithromycin and rifabutin.

In a particularly preferred embodiment there is administered to anindividual a pharmaceutical composition comprising the anti-fungal agentfluconazole and the anti-bacterial agents azithromycin and rifampicin.

In a particularly preferred embodiment there is administered to anindividual a pharmaceutical composition comprising the anti-fungal agentterbinafine hydrochloride and the anti-bacterial agents azithromycin andrifabutin.

In a particularly preferred embodiment there is administered to anindividual a pharmaceutical composition comprising the anti-fungal agentterbinafine hydrochloride and the anti-bacterial agents erythromycin andamoxycillin.

In a particularly preferred embodiment there is administered to anindividual a pharmaceutical composition comprising the anti-fungal agentterbinafine hydrochloride and the anti-bacterial agents clarithromycinand doxycycline.

Typically, systemic administration may further include one or more ofthe following: a mucolytic agent, a steroid, a decongestant and/or abronchodilator.

According to a third aspect of the present invention there is provided apharmaceutical composition for systemic administration for the treatmentof respiratory tract mucositis, the composition comprisingtherapeutically effective amounts of at least one anti-fungal agent andtwo or more anti-bacterial agents.

In a preferred embodiment of the pharmaceutical composition of theinvention the composition includes one anti-fungal agent selected fromthe above-mentioned group combined with two or more anti-bacterialagents selected from the group consisting of doxycycline,chlortetracycline, tetracycline hydrochloride, oxytetracycline,demeclocycline, methacycline, minocycline, penicillin, amoxycillin,erythromycin, clarithromycin, roxithromycin, azithromycin, spiramycin,oleandomycin, josamycin, kitsamysin, flurithromycin, nalidixic acid,oxolinic acid, norfloxacin, perfloxacin, amifloxacin, ofloxacin,ciprofloxacin, sparfloxacin, levofloxacin, rifabutin, rifampicin,rifapentin, sulfisoxazole, sulfamethoxazole, sulfadiazine, sulfadoxine,sulfasalazine, sulfaphenazole, dapsone, sulfacytidine, and linezolid.

In a particular embodiment the composition comprises the anti-fungalagent terbinafine hydrochloride and the anti-bacterial agentsdoxycycline and rifabutin.

In a particular embodiment the composition comprises the anti-fungalagent terbinafine hydrochloride and the anti-bacterial agentsclarithromycin and rifampicin.

In a particular embodiment the composition comprises the anti-fungalagent terbinafine hydrochloride and the anti-bacterial agentsdoxycycline and rifampicin.

In a particular embodiment the composition comprises the anti-fungalagent terbinafine hydrochloride and the anti-bacterial agentsclarithromycin and rifabutin.

In a particular embodiment the composition comprises the anti-fungalagent terbinafine hydrochloride and the anti-bacterial agentstetracycline hydrochloride and rifampicin.

In a particular embodiment the composition comprises the anti-fungalagent fluconazole and the anti-bacterial agents clarithromycin andrifabutin.

In a particular embodiment the composition comprises the anti-fungalagent fluconazole and the anti-bacterial agents azithromycin andrifampicin.

In a particular embodiment the composition comprises the anti-fungalagent terbinafine hydrochloride and the anti-bacterial agentsazithromycin and rifabutin.

In a particular embodiment the composition comprises the anti-fungalagent terbinafine hydrochloride and the anti-bacterial agentserythromycin and amoxycillin.

In a particular embodiment the composition comprises the anti-fungalagent terbinafine hydrochloride and the anti-bacterial agentsclarithromycin and doxycycline.

Typically, the pharmaceutical composition may further include one ormore of the following: a mucolytic agent, a steroid, a decongestantand/or a bronchodilator.

Systemic administration may be the oral or parenteral administration ofthe composition. The composition may be in any form suitable forsystemic administration, for example in the form of a capsule, tablet,caplet, solution or suspension.

The present invention further provides for the use of therapeuticallyeffective amounts of at least one anti-fungal agent and two or moreanti-bacterial agents for the manufacture of a medicament for systemicadministration for the treatment of respiratory tract mucositis.

DETAILED DESCRIPTION OF THE INVENTION

As used herein the term “treatment” refers to any and all uses whichremedy a disease state or symptoms, or otherwise prevent, hinder,retard, or reverse the progression of disease or other undesirablesymptoms in any way whatsoever. Thus, “treatment” means not onlytreatment designed to cure or remove symptoms in an individual, but alsoto ongoing therapy (so-called ‘maintenance therapy’) designed to controland suppress the occurrence of symptoms. Treatment may be for a definedperiod of time, or provided on an ongoing basis depending on theparticular circumstances of any given individual.

As used herein the term “anti-bacterial agent” refers to any agent thatis capable of killing bacteria or is used in the treatment oreradication of infections caused by bacteria. This includes bothantibiotics, isolated from natural sources and synthetically generatedanti-bacterials.

As used herein the term “emollient” refers to any product applied to theskin which soothes irritation of the skin, including, for example,ointments, liniments, lotions, creams, moisturisers, oils, skinsofteners, soaps, shampoo, sunscreens, cosmetics and the like.

As used herein the term “simultaneously” means administration within a24 hour period. That is, to realise the benefits of the embodiments ofthe invention it is not necessary that administration of each of theactive agents occur at precisely the same time, but rather that theindividual receive these agents within a given 24 hour period.

The present invention provides methods and pharmaceutical compositionsfor treating patients either with acute, chronic, or partially treatedrespiratory mucositis, in particular asthma, rhinosinusitis, allergicrhinitis, chronic bronchitis, sinusitis, emphysema and cysticfibrosis-associated lung disease. Preferred embodiments of the presentinvention provide combinations of anti-fungal and anti-bacterial agentswhich can be used for the effective treatment of deeply seated fungaland bacterial infections which lead to these inflammation states. Theanti-bacterial agents used in preferred forms of the present inventionare antibiotics or other anti-bacterial agents which are suitable forthe eradication of various bacterial infections.

The present invention is based on the discovery by the Applicant thatfungal and bacterial infections which are deep in the mucosal cellularstructures, can be treated effectively by systemic administration ofcompositions which include anti-fungal and anti-bacterial agents. Unlikemuco-administration of various active agents the systemic therapy of thepresent invention offers for the first time a viable long term treatmentand/or prevention option for sufferers of respiratory tract mucositis.

The present invention teaches compositions and treatments which arecontrary to the current understanding of chronic allergic asthma andrhino-sinusitis. Additionally, the present invention provides treatmentswhich avoid surgery for rhino-sinusitis and avoids steroid use which isgenerally required for asthma treatment.

Administration

Administration of anti-fungal and anti-bacterial agents according topreferred embodiments of the present invention may be by oral,intravenous, intra-arterial, intramuscular, or subcutaneous routes.Typically, administration is by the oral route.

In the methods of the present invention the at least one anti-fungalagent and at least one anti-bacterial agent may be administered insingle daily doses, or in two, three, four or more identical ordifferent divided doses per day, and they may be administeredsimultaneously or at different times during the day. Usually, the activesubstances will be administered simultaneously. They may be contained inseparate medications, or more usually in a single combined dosage form.

Anti-fungal and Anti-bacterial Agents

Anti-fungal agents for use according to the methods of the presentinvention and in compositions of the present invention are preferablyselected from the groups consisting of: polyene macrolide, tetrenemacrolide, pentaenic macrolide, fluorinated pyrimidine, imidazole,azole, triazole, halogenated phenolic ether, thiocarbamate, allylamine,sterol inhibitor, or an agent that interpolates fungal cellconstituents. Preferably the anti-fungal agent is selected from thefollowing group: amphotericin B, flucytosine, ketoconazole, miconazole,itraconazole, fluconazole, griseofulvin, clotrimazole, econazole,terconazole, butoconazole, oxiconazole, sulconazole, supraconazole,voriconazole, ciclopirox olamine, haloprogin, tolnaftate, naftifine,terbinafine hydrochloride, morpholines, nystatin, natamycin, butenafine,undecylenic acid, proprionic acid and caprylic acid. Preferably theanti-fungal agent is selected from the following sub-group: amphotericinB; ketoconazole; fluconazole; and terbinafine hydrochloride.

In combination with the anti-fungal agent or agents this inventionincludes the co-administration of one or more anti-bacterial agents,preferably being selected from a group consisting of tetracyclines,penicillins, macrolides, quinolones, chloramphenicol, rifamycins,sulphonamides, co-trimoxazole, and oxazolidinones. Examples of theseantibiotics include, among others, doxycycline; chlortetracycline;tetracycline hydrochloride; oxytetracycline; demeclocycline;methacycline; minocycline; penicillin; amoxycillin; erythromycin;clarithromycin; roxithromycin; azithromycin; spiramycin; oleandomycin;josamycin; kitsamysin; flurithromycin; nalidixic acid; oxolinic acid;norfloxacin; perfloxacin; amifloxacin; ofloxacin; ciprofloxacin;sparfloxacin; levofloxacin; rifabutin; rifampicin; rifapentin;sulfisoxazole; sulfamethoxazole; sulfadiazine; sulfadoxine;sulfasalazine; sulfaphenazole; dapsone; sulfacytidine; or linezolid aswell as other examples of each group of antibiotics enumerated.

In one preferred form the composition of the present invention comprisesone anti-fungal and two anti-bacterial agents.

In an alternative form the composition of the present inventioncomprises two anti-fungal agents and two, three or more anti-bacterialagents.

Preferred Combinations and Dosages

The doses of the anti-fungal agents and anti-bacterial agents used inthe pharmaceutical compositions according to preferred forms of thepresent invention are in accordance with their generally known andestablished safe dosage ranges when they are used in monotherapy for thetreatment of other conditions. Such dosages for anti-bacterial agentsare understood by those skilled in the art and generally range from0.0005 to 50 grams per day, depending on the agent used, as describedfor example in Martindale, The Extra Pharmacopoeia, 31 st Edition (TheRoyal Pharmaceutical Society, London, 1996).

The therapeutically effective amount of anti-fungal and anti-bacterialagents for any particular patient will depend upon a variety of factorsincluding: the disorder being treated and the severity of the disorder;the composition employed; the age, body weight, general health, sex anddiet of the patient; the time of administration; the route ofadministration; the duration of the treatment; drugs used in combinationor coincidental with the treatment, together with other related factorswell known in medicine.

One skilled in the art would be able, by routine experimentation, todetermine an effective, non-toxic amount of the anti-fungal andanti-bacterial agents which would be required to treat the disorders anddiseases to which the present application is applicable.

Typically, an effective dose of the appropriate anti-fungal agent(s) andanti-bacterial agent(s) would be expected to be in the range of about 1milligram (mg) per day to about 4 grams (g) per day, preferably about 10mg per day to about 2 g per day, even more preferably about 100 mg perday to about 1000 mg per day.

In one preferred embodiment of the method of the present invention thereare administered to a patient terbinafine hydrochloride in an amount of250 mg per day, doxycycline in an amount of 100 mg per day and rifabutinin an amount of 150 mg per day. Preferably administration is oral, twicedaily for a period of between one week and six months.

In another preferred method in accordance with the invention, there areadministered to a patient terbinafine hydrochloride (250 mg per day),clarithromycin (500 mg per day) and rifampicin (300 mg per day).Preferably administration is oral, twice daily. Such a method oftreatment, adjusted to reflect the child's weight, is particularlysuitable for administration to children. An alternative effectivetreatment for children involves the administration of a syrup containingone anti-fungal agent in the form of terbinafine hydrochloride and oneanti-bacterial agent in the form of clarithromycin.

In a further preferred method in accordance with the invention there areadministered to a patient terbinafine hydrochloride (250 mg per day),doxycycline (100 mg per day) and rifampicin (300 mg per day). Preferablyadministration is oral, twice daily for a period of two months.

In a further preferred method in accordance with the invention there areadministered to a patient terbinafine hydrochloride (250 mg per day),clarithromycin (250 mg per day) and rifabutin (150 mg per day).Preferably administration is oral, twice daily for a period of 1 week to1 year.

In a further preferred method in accordance with the invention there areadministered to a patient terbinafine hydrochloride (250 mg per day),tetracycline hydrochloride (500 mg per day) and rifampicin (300 mg perday). Preferably administration is oral, twice daily for a period of 1to 3 months.

In a further preferred method in accordance with the invention there areadministered to a patient fluconazole (200 mg per day), clarithromycin(500 mg per day) and rifabutin (150 mg per day). Preferablyadministration is oral, twice daily for a period of 1 to 3 months.

In a further preferred method in accordance with the invention there areadministered to a patient terbinafine hydrochloride (250 mg per day),erythromycin (1000 mg per day) and amoxycillin (1000 mg per day).Preferably administration is oral, twice daily.

In a further preferred method in accordance with the invention there areadministered to a patient terbinafine hydrochloride (500 mg per day),clarithromycin (500 mg per day) and doxycycline (100 mg per day).Preferably administration is oral, twice daily.

It will be appreciated by those skilled in the art that the dosagesprovided in the above preferred methods are merely indicative of typicaldosages of the specific anti-fungal agents and anti-bacterial agentslisted. Actual doses of each active agent administered to any givenindividual may vary and will depend on a variety of factors including:the disorder being treated and the severity of the disorder; thecomposition employed; the age, body weight, general health, sex and dietof the individual; the time of administration; the route ofadministration; the duration of the treatment; drugs used coincidentalwith the treatment, together with other related factors well known inmedicine. For example, dosage amounts higher than those provided in theabove preferred methods may be employed in the case of resistant fungaland bacterial infections.

Administration of the relevant composition will be determined on a caseby case basis, and may for example be once, twice, three or more timesdaily. The component medications may be taken simultaneously orseparately. The duration of the treatment will depend on the severityand resistance of the underlying condition. Treatment may be prescribedfor a duration of one week to one year or more, but typically for two tothree months.

Patient response to the treatment may be measured by noting clinicalimprovement, progressive reduction of reliance upon typical asthma drugssuch as steroids and bronchodilators, the improvement in peak flow, andpatient well-being and performance.

Pharmaceutical Compositions

One preferred pharmaceutical composition in accordance with theinvention comprises terbinafine hydrochloride in an amount of 125 mg,doxycycline in an amount of 50 mg and rifabutin in an amount of 75 mg.

Another preferred pharmaceutical composition in accordance with theinvention comprises terbinafine hydrochloride in an amount of 125 mg,clarithromycin in an amount of 250 mg and rifampicin in an amount of 150mg.

A further preferred pharmaceutical composition in accordance with theinvention comprises terbinafine hydrochloride in an amount of 125 mg,doxycycline in an amount of 50 mg and rifampicin in an amount of 150 mg.

Yet another preferred pharmaceutical composition in accordance with theinvention comprises terbinafine hydrochloride in an amount of 125 mg,clarithromycin in an amount of 125 mg and rifabutin in an amount of 75mg.

Yet another preferred pharmaceutical composition in accordance with theinvention comprises terbinafine hydrochloride in an amount of 125 mg,tetracycline hydrochloride in an amount of 250 mg and rifampicin in anamount of 150 mg.

Yet another preferred pharmaceutical composition in accordance with theinvention comprises fluconazole in an amount of at least 100 mg,clarithromycin in an amount of at least 250 mg and rifabutin in anamount of at least 75 mg.

Yet another preferred pharmaceutical composition in accordance with theinvention comprises terbinafine hydrochloride in an amount of 125 mg,erythromycin in an amount of 500 mg and amoxycillin in an amount of 500mg. Preferably the composition is administered twice daily.

Yet another preferred pharmaceutical composition in accordance with theinvention comprises terbinafine hydrochloride in an amount of 250 mg,clarithromycin in an amount of 250 mg and doxycycline in an amount of 50mg. Preferably the composition is administered twice daily.

A pharmaceutical composition according to the present invention mayinclude one or more pharmaceutically acceptable excipients, adjuvants,diluents or carriers which are generally known in the art.

For oral administration, the pharmaceutical composition may be in theform of tablets, lozenges, pills, troches, capsules, elixirs, powders,including lyophilised powders, solutions, granules, suspensions,emulsions, syrups and tinctures. Slow release, or sustained releaseforms may also be prepared, for example in the form of coated particles,multi-layer tablets or microgranules. It is preferable for prolongedaction that the composition be in a slow or sustained release form.

Solid forms for oral administration may contain pharmaceuticallyacceptable binders, sweeteners, disintegrating agents, diluents,flavourings, coating agents, preservatives, lubricants and/or time delayagents. Suitable binders include gum acacia, gelatin, corn starch, gumtragacanth, sodium alginate, carboxymethylcellulose or polyethyleneglycol. Suitable sweeteners include sucrose, lactose, glucose, aspartameor saccharine. Suitable disintegrating agents include corn starch,methylcellulose, polyvinylpyrrolidone, xanthan gum, bentonite, alginicacid or agar. Suitable diluents include lactose, sorbitol, mannitol,dextrose, kaolin, cellulose, calcium carbonate, calcium silicate ordicalcium phosphate. Suitable flavouring agents include peppermint oil,oil of wintergreen, cherry, orange or raspberry flavouring. Suitablecoating agents include polymers or copolymers of acrylic acid and/ormethacrylic acid and/or their esters, waxes, fatty alcohols, zein,shellac or gluten. Suitable preservatives include sodium benzoate,vitamin E, alpha-tocopherol, ascorbic acid, methyl paraben, propylparaben or sodium bisulphite. Suitable lubricants include magnesiumsterate, steraic acid, sodium oleate, sodium chloride or talc. Suitabletime delay agents include glyceryl monosterate or glyceryl disterate.

Liquid forms for oral administration may contain in addition to theactive agents, a liquid carrier. Suitable liquid carriers include water,oils such as olive oil, peanut oil, sesame oil, sunflower oil, saffloweroil, arachis oil, coconut oil, liquid paraffin, ethylene glycol,propylene glycol, polyethylene glycol, ethanol, propanol, isopropanol,glycerol, fatty alcohols, triglycerides or mixtures thereof.

Suspensions for oral administration may further include dispersingagents and/or suspending agents. Suitable suspending agents includesodium carboxymethylcellulose, methylcellulose,hydroxypropylmethyl-cellulose, poly-vinyl-pyrrolidine, sodium alginateor cetyl alcohol. Suitable dispersing agents include lecithin,polyoxyethylene esters of fatty acids such as stearic acid,polyoxyethylene sorbitol mono- or di-oleate, -stearate or laurate,polyoxyethylene sorbitan mono- or di-oleate, -stearate or -laurate andthe like.

Pharmaceutical compositions of the present invention may be prepared byblending, grinding, homogenising, suspending, dissolving, emulsifying,dispersing and/or mixing the anti-fungal agent(s) and the anti-bacterialagent(s) together with the selected excipient(s), carrier(s),adjuvant(s) and/or diluent(s). One type of pharmaceutical composition ofthe present invention in the form of a tablet or capsule may be preparedby (a) preparing a first tablet comprising at least one of the activesubstances together with any desired excipient(s), carrier(s),adjuvant(s) and/or diluent(s), and (b) preparing a second tablet or acapsule, wherein the second tablet or the capsule includes the remainingactive substance(s) and the first tablet. Another type of pharmaceuticalcomposition of the present invention in the form of a capsule may beprepared by (a) preparing a first capsule comprising at least one of theactive substances together with any desired excipient(s), carrier(s),adjuvant(s) and/or diluent(s), and (b) preparing a second capsule,wherein the second capsule includes the remaining active substance(s)and the first tablet. A further type of pharmaceutical composition ofthe present invention in the form of a tablet may be prepared by (a)preparing a capsule comprising at least one of the active substancestogether with any desired excipient(s), carrier(s), adjuvant(s) and/ordiluent(s), and (b) preparing a tablet, wherein the tablet includes theremaining active substance(s) and the capsule.

A pharmaceutical composition of the present invention that comprises atleast one anti-fungal agent and at least one anti-bacterial agent may beprovided with the active substances contained within a single capsulefor monotherapeutic administration. In one form of such a composition,the at least one anti-fungal agent may be contained within an innercapsule or tablet, the inner capsule or tablet being surrounded by theat least one anti-bacterial agent contained within an outer capsule. Itwill be appreciated that the locations of the components may be reversedsuch that the at least one anti-bacterial agent may be contained withinthe inner capsule or tablet and the at least one anti-fungal agent maybe contained within the outer capsule. This arrangement will beespecially desirable if the active substances are likely to cross-reactif contained within the same capsule.

In compositions that comprise three active substances in the form of oneanti-fungal agent and two anti-bacterial agents, one active substancemay be contained within a central coated tablet or capsule and theremaining two active substances may be contained in an outer capsule inthe form of coated microspheres. Other combinations for presentation ofthe combination of three active substances are possible.

The present invention will now be described by reference to specificExamples, which should not in any way be construed as limiting the scopeof the invention. Examples 3 to 5 represent case studies illustratingthe effectiveness of preferred embodiments of the treatments andcompositions of the present invention.

EXAMPLES Example 1

A pharmaceutical composition is made with terbinafine hydrochloride,doxycycline and rifampicin in the proportions of 2.5:1:3 by weight,blended and encapsulated into a gelatin capsule, each capsule containing125 mg terbinafine hydrochloride, 50 mg doxycycline and 150 mgrifampicin.

Example 2

For the treatment of children, a pharmaceutical composition is made withterbinafine hydrochloride, clarithromycin and rifampicin in theproportions of 1:2:1.2 by weight, blended and encapsulated into agelatin capsule, each capsule containing 125 mg terbinafinehydrochloride, 250 mg clarithromycin and 150 mg rifampicin.

The pharmaceutical composition is self-administered by the patient twicedaily for a period of between two months and four months. The progressof the patient may be monitored if desired by measurement of peak flowrates.

Example 3

A 74 year old male with onset of asthma two years prior was chronicallytreated with standard bronchodilators (Ventolin) and steroid inhalantsand intermittent antibiotics. He continued to be symptomatic throughoutthe treatment with mild to severe episodes.

He was commenced on a combination of terbinafine hydrochloride (250 mgper day), doxycycline (50 mg twice a day), and rifabutin (150 mg perday). After only two weeks of treatment his peakflow meter readingsimproved twofold and by three months of treatment he had ceased all hissteroid and Ventolin therapies. His peakflow meter range reading was atthis stage normal for his age. One month later he continued to betotally free of symptoms without any further anti-asthmatic treatment,and at 13 months no further anti-asthma therapy has been required.

Example 4

A 28 year old female with a chronic history of recurrent admissions tohospital and use of oral as well as inhaled steroids and bronchodilatorsand recurrent use of antibiotics during triggered attacks, was commencedon a combination of terbinafine hydrochloride (250 mg in the morning),clarithromycin (250 mg twice a day), and rifampicin (150 mg twice a day)in the form of a syrup. She was unable to swallow tablets adequately andpreferred the syrup which was given bid. Within two weeks of treatmentshe was able to dispense with all other therapies for asthma and atthree months continues well with peakflow readings that are now normalfor her age, having previously been severely restricted in her dailyactivities and work because of recurrent asthma on maximal standardtherapies.

Example 5

A 68 year old male with recurrent rhino-sinusitis but without nasalpolyps had been treated by an ear nose and throat specialist withvarious antibiotics over several years. Though the symptoms improvedafter each course of antibiotics they nevertheless recurred. There wasno associated asthma.

The patient was commenced on a course of terbinafine hydrochloride (250mg per day), doxycycline (50 mg twice a day), and rifampicin (150 mgtwice a day) for 2 months. Within 1 week of starting treatment hissymptoms disappeared. The patient completed the 2 month course andremains asymptomatic at 14 months and when reviewed at 20 months.

Example 6

A 34 year old obese female with history of severe asthma with steroiddependence and three documented respiratory then cardiac arrests, wascommenced on the combination of terbinafine hydrochloride 250 mg twicedaily, clarithromycin 250 mg twice daily and doxycycline 50 mg bid. Thisallowed the patient—after three weeks—to completely remove her steroidswhich she was using at a dose of 10 mg per day (Prednisone). Her asthmasymptoms resolved progressively at about the same time. However shestill continued to take Ventolin and Beclomethasone.

Over the following four weeks the patient was able to reduce and theneliminate the use of Ventolin and the Beclomethasone without any daytime or nocturnal wheezing. There was no cough as there had been in thepast, the patient reported feeling well, indeed much better than she hadfor many years. However, she developed some nausea and dizziness whichwas attributed by her local doctor to doxycycline, who then ceased thedoxycycline. The patient continued on the clarithromycin 250 mg bd andterbinafine hydrochloride 250 mg bd.

After three months of treatment, the last month of which had been ondouble therapy not triple, the patient ceased the medication and withinthree weeks had a recurrence of asthma. Recommencement of the sametherapy with higher dose of clarithromycin and doxycycline againcontrolled the disease and the patient was able to come off all steroidsand Ventolin therapy by week four. At this time Doxycycline andClarithromycin doses were reduced but terbinafine hydrochloridecontinues at 250 mg bd. The patient did not dare go off the medicationfor the next six months as she feared developing anothercardiac-respiratory arrest.

This Case exemplifies that reduction of dosage or cessation therapy maylead to the possible developing of resistance to antifungal/antibioticinfection, and at the same time exemplifies the concept of maintenancetherapy on antibiotics for asthma to completely control the asthmawithout necessarily eradicating the infection.

1. A method for the treatment of the invasive component of aco-infection with a fungi and a bacterium associated with respiratorytract mucositis in an individual in need of said treatment, the methodcomprising the systemic administration to the individual oftherapeutically effective amounts of at least one anti-fungal agent andat least one anti-bacterial agent, wherein the treatment does notinvolve the cessation or reduction of use of emollients by theindividual, wherein said mucositis is associated with a co-infection ofat least one fungi and at least one bacterium.
 2. A method for thetreatment of the invasive component of fungal or bacterial infectionassociated with respiratory tract mucositis in an individual in need ofsaid treatment, said method comprising the systemic administration tothe individual of therapeutically effective amounts of at least oneanti-fungal agent and two or more anti-bacterial agents.
 3. The methodaccording to claim 2, wherein said treatment further includes thereduction or cessation of use of emollients by the individual.
 4. Themethod according to claim 2 wherein said at least one anti-fungal agentis selected from the group consisting of: amphotericin B, flucytosine,ketoconazole, miconazole, itraconazole, fluconazole, griseofulvin,clotrimazole, econazole, terconazole, butoconazole, oxiconazole,sulconazole, supraconazole, voriconazole, ciclopirox olamine,haloprogin, tolnaftate, naftifine, terbinafine hydrochloride,morpholines, nystatin, natamycin, butenafine, undecylenic acid,proprionic acid and caprylic acid.
 5. The method according to claim 2wherein anti-bacterial agents belong to one or more of the followingclasses: tetracyclines, penicillins, macrolides, quinolones,chloramphenicol, rifamycins, sulphonamides, co-trimoxazole, andoxazolidinones.
 6. The method according to claim 5 wherein saidanti-bacterial agents are selected from the group consisting of:doxycycline, chlortetracycline, tetracycline hydrochloride,oxytetracycline, demeclocycline, methacycline, minocycline, penicillin,amoxycillin, erythromycin, clarithromycin, roxithromycin, azithromycin,spiramycin, oleandomycin, josamycin, kitsamysin, flurithromycin,nalidixic acid, oxolinic acid, norfloxacin, perfloxacin, amifloxacin,ofloxacin, ciprofloxacin, sparfloxacin, levofloxacin, rifabutin,rifampicin, rifapentin, sulfisoxazole, sulfamethoxazole, sulfadiazine,sulfadoxine, sulfasalazine, sulfaphenazole, dapsone, sulfacytidine, andlinezolid.
 7. The method according to claim 2 wherein said treatmentcomprises the systemic administration of one anti-fungal agent and twoanti-bacterial agents.
 8. The method according to claim 7 wherein theanti-fungal agent is terbinafine hydrochloride and the anti-bacterialagents are doxycycline and rifabutin.
 9. The method according to claim 7wherein the anti-fungal agent is terbinafine hydrochloride and theanti-bacterial agents are clarithromycin and rifampicin.
 10. The methodaccording to claim 7 wherein the anti-fungal agent is terbinafinehydrochloride and the anti-bacterial agents are doxycycline andrifampicin.
 11. The method according to claim 7 wherein the anti-fungalagent is terbinafine hydrochloride and the anti-bacterial agents areclarithromycin and rifabutin.
 12. The method according to claim 7wherein the anti-fungal agent is terbinafine hydrochloride and theanti-bacterial agents are tetracycline hydrochloride and rifampicin. 13.The method according to claim 7 wherein the anti-fungal agent isfluconazole and the anti-bacterial agents are clarithromycin andrifabutin.
 14. The method according to claim 7 wherein the anti-fungalagent is fluconazole and the anti-bacterial agents are azithromycin andrifampicin.
 15. The method according to claim 7 wherein the anti-fungalagent is terbinafine hydrochloride and the anti-bacterial agents areazithromycin and rifabutin.
 16. The method according to claim 7 whereinthe anti-fungal agent is terbinafine hydrochloride and theanti-bacterial agents are erythromycin and amoxycillin.
 17. The methodaccording to claim 7 wherein the anti-fungal agent is terbinafinehydrochloride and the anti-bacterial agents are clarithromycin anddoxycycline.
 18. The method according to claim 2 wherein said treatmentcomprises the systemic administration of two anti-fungal agents and twoor more anti-bacterial agents.
 19. The method according to claim 2wherein said anti-fungal and anti-bacterial agents are administeredsequentially.
 20. The method according to claim 2 wherein saidanti-fungal and anti-bacterial agents are administered simultaneously.21. The method according to claim 2 wherein said method further includesthe administration of one or more of a mucolytic agent, a steroid, adecongestant and/or a bronchodilator.
 22. The method according to claim2 wherein said respiratory tract mucositis is asthma, rhinosinusitis,allergic rhinitis, chronic bronchitis, sinusitis, emphysema or cysticfibrosis-associated lung disease.
 23. A method for the treatment of theinvasive component of a co-infection of a fungi and a bacteriumassociated with respiratory tract mucositis comprising administering toa patient in need thereof a pharmaceutical composition comprisingtherapeutically effective amounts of at least one anti-fungal agent andtwo or more anti-bacterial agents, wherein said mucositis is associatedwith a co-infection of at least one fungi and at least one bacterium.24. The method according to claim 7 wherein the anti-fungal agent isitraconazole hydrochloride and the anti-bacterial agents are doxycyclineand rifabutin.
 25. The method according to claim 7 wherein theanti-fungal agent is itraconazole hydrochloride and the anti-bacterialagents are clarithromycin and rifampicin.
 26. The method according toclaim 7 wherein the anti-fungal agent is itraconazole hydrochloride andthe anti-bacterial agents are doxycycline and rifampicin.
 27. The methodaccording to claim 7 wherein the anti-fungal agent is itraconazolehydrochloride and the anti-bacterial agents are clarithromycin andrifabutin.
 28. The method according to claim 7 wherein the anti-fungalagent is itraconazole hydrochloride and the anti-bacterial agents aretetracycline hydrochloride and rifampicin.